From January 2001 NASW NEWS
Copyright ©2001, National Association of Social Workers, Inc.

Online Therapy on Verge of Major Launch

Susan Mankita leads Social Work 2000 workshop.

For-profit companies want to sign up thousands of social workers as contractors.

By John V. O'Neill, MSW, NEWS Staff

Online therapy services soon will sweep across the staid world of psychotherapy like a sunami, and many social workers are rushing to get ahead of the wave, said Susan Mankita, who heads America OnLine's Social Work Forum, at NASW's Social Work 2000 conference in Baltimore in November.

In the next month or two, one of the for-profit companies that have been signing up clinicians will unleash an advertising blitz, and online therapy services will move from the start-up stage to public consciousness in a big way, said Mankita. "We will see it any day now in the news, on talk shows or in advertising."

For-profit companies are competing to sign up large numbers of social workers and others in anticipation of soon being operational, said Mankita, who easily signed up 500 social workers to offer online therapy for one company.

"They want social workers and networks with thousands and thousands of clinicians," said Mankita, of Miami, who has become something of an online social work guru and was primarily responsible for establishing the Cyber Cafe at the conference.

Social workers' attitudes toward e-therapy have shifted rapidly, she said. "In the past I would spend 10 minutes talking about online therapy, and they would say, 'Nah, we're not ready for that yet.' Now they ask, 'Where do I sign up? Who should I sign up with? How much should I charge? What kinds of clients should I treat? Will my liability insurance cover this? How can I do this effectively and safely?'"

Many social workers are signing up with online therapy companies because they have been marketed heavily and it is presented to them in a very positive way as a low-risk means of making extra money from the comforts of home with no office expense. "They give you a virtual office, Web page, assess for suicide risk, do practice management, bill for you and send you a check in the mail." Social workers "are exploring it enthusiastically, I would say," said Mankita. "They want to get in on the beginning of this wave."

"I'm not saying this should be done without great care, but this is happening all around us, and if we don't proceed, we will be shut out of the market," she said.

To get around the problem of state-specific clinical licenses, the online companies want large numbers of clinicians in every state, to give callers a choice in the states where they live and because the more clinicians companies have under contract, the more clients they can serve and the more money they can make, said Mankita. "They want hundreds of social workers in the big states. And they have expanded to psychologists."

Mankita offered other insights on the emerging world of online therapy.

How it works. Social workers are free to practice online therapy on their own, setting up and advertising their own Web pages. Some social workers may only want to use the Internet as a means to try to encourage clients to come to an office for face-to-face therapy, and companies may discourage that.

In some for-profit company models, there is no charge to clinicians. If, for instance, a clinician charges $40 for an e-mail session, the company might charge the client $46 on his or her credit card and keep the $6 as a practice management fee. There might also be advertising.

In another model, there would be no advertising, but clinicians would be charged $20 per month for a virtual office.

Social workers could set any fees they chose, but might do an online check to see what others charge, since the amount of business they get will depend on competitiveness.

Clients will pay by credit card, and practitioners will be mailed a check for their share about twice a month.

Practitioners are completely responsible for clinical interventions.

Insurance companies cover online therapy, but the first time there is a lawsuit it may become a rider.

Training and online expertise. Because of the missing visual and voice cues, social workers need more than clinical skills to do online counseling. It requires practice and learning techniques like the use of "emoticons," figures that indicate emotions, as a way to reach an understanding of feelings and emotions behind words.

Another technique is to "textualize your emotions and physical reactions." A clinician might say to a client, "I hear that you're hurting right now." If that is done for clients, they will respond in kind.

In group work, a back channel like instant messaging might be used to ask a silent client what's going on.

Group chats are helpful in learning techniques.

Continuing education is strongly suggested before trying online therapy.

Therapists should use simple modalities at first, like e-mail, before going to chat.

Some online therapy companies make training available.

If clinicians aren't trained to do it right, "we are abandoning our professional mission, vision and values to make sure that we responsibly offer services to clients that help them," said Mankita. "It will be a steep learning curve."

Advantages. The reason text-based therapy will be so effective is that people are much more willing to reveal shameful material from behind the anonymity of a computer. "It is harder to reveal yourself by telephone, and harder still by video," Mankita said.

It is good for people in rural areas where few clinicians are available and for people like women with small children who need to be at home.

Confidentiality. Clinicians will have to learn new ways of protecting confidential client information, and that's going to require computer savvy, since they will have to manage their own records.

Now is the time to have influence on online therapy companies, said Mankita. One company wanted to keep records until social workers told them that it would violate their ethical responsibility to maintain confidentiality.

The future. Initial clients will be middle class or upper-middle class and will pay by credit card.

But companies are beginning to get contracts with employee assistance programs and are seeking contractual arrangements with a variety of organizations and companies to provide online therapy to their members or employees, meaning online therapy may become part of practice in many areas.

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